Specimen site: Gastric biopsy
Gross description: Gastric biopsy: Received in formalin, the specimen consists of two fragments of gray-brown mucosa, each measuring approximately 0.3 centimeter in diameter. Totally submitted for routine and special stains and additional levels.
Microscopic description: Sections show benign-appearing gastric mucosa with acute and chronic inflammatory cells within the lamina propria. The surface and pit-lining epithelium are also infiltrated with neutrophils. There is no dysplasia or malignancy. Special stains for H. pylori are positive.
Final diagnosis:
Gastric biopsy:
? Chronic active gastritis.
? Warthin-Starry stain positive for H. pylori.
? Negative for intestinal metaplasia, dysplasia, or malignancy.
Select the appropriate ICD-10-CM and CPT code(s):

Question

Quizplus · Accepted Answer

The diagnosis of chronic active gastritis and the presence of H. pylori infection are coded as K29.50 and B96.81, respectively. The CPT codes 88305 for the biopsy and 88312 for the special stains (e.g., for H. pylori) accurately reflect the procedures described in the specimen processing.

Specimen Site: Gastric Biopsy